The workers’ compensation insurance system is a no-fault method of paying workers for medical expenses and wage losses due to injuries while on duty of their jobs. While the majority of workers’ compensation claims are truthful, the National Insurance Crime Bureau reports that billions of dollars of false claims are submitted each year. To help you detect possible workers’ compensation fraud, experience shows a claim may be fraudulent if two or more of the following factors related to fraud are present:
- Monday Morning: The alleged injury occurs either “first thing Monday morning” or late on a Friday afternoon, but not reported until Monday.
2. Employment Change: The reported accident occurs immediately before or after a strike, layoff, and the end of a big project or at the conclusion of seasonal work.
3. Job Termination: If an employee files a post-termination claim:
– Did the employee prior to termination report the alleged injury?
– Did the employee exhaust his/her unemployment benefits prior to claiming workers’
compensation benefits?
4. History of Changes: The claimant has a history or frequently changing physicians, addresses, and places of employment.
5. Medical History: The employee has a pre-existing medical condition that is similar to the alleged work injury.
6. No Witnesses: The accident has no witnesses, and the employee’s own description does not logically support the cause of injury.
7. Conflicting Descriptions: The employee’s description of the accident conflicts with the medical history or First Report of Injury.
8. History of Claims: The claimant has a history of numerous suspicious or litigated claims.
9. Treatment is refused: The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.
10. Late Reporting: The employee delays reporting the claim without a reasonable explanation.
11. Hard to Reach: You have difficulty contacting a claimant at home, when he/she is allegedly disabled.
12. Moonlighting: Does the employee have another paying job or do volunteer work?
